An eclectic, iconoclastic, independent, private, non-commercial blog begun in 2010 in support of the federal Meaningful Use REC initiative, and Health IT and Heathcare improvement more broadly. Formerly known as "The REC Blog." Best viewed with Safari, FireFox, or Chrome (anything but IE).
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Monday, May 16, 2016

EHRs and the ACA: Obama's diabolical plot to enslave physicians

Hang around enough health IT and health policy blogs for any sustained length of time (in particular delving into and participating in the always-fractious comments sections), and you will by now have become utterly familiar with the overwrought, cynical sentiment set forth in the above title. Nothing is ever incrementally better or worse, it's always an existential catastrophe or a totally beneficent "transformative new era in health care." EHRs are uniformly "dangerous, untested, experimental medical devices that harm and kill patients" (which, of course, begs the fundamental question that, if they're "untested," how, precisely, can we summarily know they're causally dangerous?). And, ObamaCare isindisputably"the worst thing since slavery" (according to one very prominent neurosurgeon and former GOP presidential candidate, no less).

You know the riff.

All part of a larger opus, one particularly, predictably notable during this fractious 2016 "money = speech" national election year. Now-failed GOP Oval Office candidate Senator Ted Cruz ominously warns that the nation is "facing the abyss," that "your religious freedoms and 2nd Amendment rights are in dire peril," and that Hillary will "appoint five radical left-wing extremist judges to the Supreme Court" if elected. Oh, the Horrors.

Right.

I particularly love how all of these Republican contenders are going to "repeal ObamaCare on Day One" -- all of them having apparently been out sick (albeit with good health insurance) during Article II day in ConLaw.

Equally uniform is the GOP candidates' heartwarming apple-pie assertion that they're going to "return control of health care to the patients."

Perhaps, amid other vague "reforms," by putting their medical data back on paper charts?

When Did Optimism Become Uncool...most American social indicators have been positive at least for years, in many cases for decades. The country is, on the whole, in the best shape it’s ever been in. So what explains all the bad vibes?

Social media and cable news, which highlight scare stories and overstate anger, bear part of the blame. So does the long-running decline in respect for the clergy, the news media, the courts and other institutions. The Republican Party’s strange insistence on disparaging the United States doesn’t help, either.

But the core reason for the disconnect between the nation’s pretty-good condition and the gloomy conventional wisdom is that optimism itself has stopped being respectable. Pessimism is now the mainstream, with optimists viewed as Pollyannas. If you don’t think everything is awful, you don’t understand the situation!...

Pollution, discrimination, crime and most diseases are in an extended decline; living standards, longevity and education levels continue to rise. The American military is not only the world’s strongest, it is the strongest ever. The United States leads the world in science and engineering, in business innovation, in every aspect of creativity, including the arts...

Manufacturing jobs described by Mr. Trump and Mr. Sanders as “lost” to China cannot be found there, or anywhere. As Charles Kenny of the nonpartisan Center for Global Development has shown, technology is causing factory-floor employment to diminish worldwide, even as loading docks hum with activity. This transition is jarring to say the least — but it was always inevitable. The evolution of the heavy-manufacturing sector away from workers and toward machines will not stop, even if international trade is cut off completely...

The lack of optimism in contemporary liberal and centrist thinking opens the door to Trump-style demagogy, since if the country really is going to hell, we do indeed need walls. And because optimism has lost its standing in American public opinion, past reforms — among them environmental protection, anti-discrimination initiatives, income security for seniors, auto and aviation safety, interconnected global economics, improved policing and yes, Obamacare — don’t get credit for the good they have accomplished.

In almost every case, reform has made America a better place, with fewer unintended consequences and lower transaction costs than expected. This is the strongest argument for the next round of reforms. The argument is better made in positive terms — which is why we need a revival of optimism...

"We need a revival of optimism." While I would tend to agree in principle, I won't be holding my breath this year.

"My optimism is off the chart. I got it from Asia, where I saw how quickly civilizations could move from abject poverty to incredible wealth. If they can do it, almost anything is possible. Let me go back to the original quote about seeing God in a cell phone: The reason we should be optimistic is life itself. It keeps bouncing back even when we do horrible things to it. Life is brimming with possibilities, details, intelligence, marvels, ingenuity. And the Technium is very much an extension of that possibility space." -- Interview with Kevin Kelly – “My Optimism Is Off The Chart”

I'm loving his book "Out of Control" (now free pdf), and can't wait to read his forthcoming one.

Given the financial imperatives of our news media, it's unsurprising that they are predisposed to fan the flames of pessimism and controversy, to stoke the fires of negativism and cynicism. "If it bleeds it leads" goes the venerable media marketing axiom. Acrimony and reflexive disputation sell (whether pertaining to politics or other topics).

Whether what they sell is increasingly toxic to the body politic and humanity writ large is quite another matter.

BTW, for a rational review of some of the actual pros and cons of the ACA ("ObamaCare") see my review last year of Jed Graham's book "ObamaCare is a Great Mess." As I noted last July:

All of the advances in medical science (and clinical pedagogy), health IT, and progressive delivery process QI we can muster will still be hemmed in by national policy. Will we continue to experience our health care in the "Shards" of my recent characterization? Will the ACA be complicit in that chronic fragmentation?

With respect to the actual utility and challenges associated with Health IT, you simply can't do any better than spending significant time over at Dr. Jerome Carter's EHR Science.

UPDATE: MS. GUR-ARIE IS AT IT AGAIN

Health Care is Not a SystemThe Merriam-Webster dictionary has many definitions for the term system, but the most straightforward, and arguably the most applicable to our health care conversation is “a regularly interacting or interdependent group of items forming a unified whole”. The common wisdom is that our health care system is broken and hence our government is vigorously attempting to fix it for us through legislation, reformation and transformation. We usually work ourselves into a frenzy arguing how the government should go about fixing the system, but I would like to take a step back and question the assumption that health care is, or should be, a system. This is not about splitting the hairs of semantics. This is about proper definition of the problem we wish to solve.

You could argue that we use the term system loosely to refer to everything and there are no nefarious implications to calling health care a system. We have a transportation system, an education system, a legal system, a financial system, a water system, a political system and so forth. Note however that we rarely talk about our food system or auto system, fashion system, hospitality system, etc. We call those industries. Starting to see a difference here? Good. Our government obviously regulates both systems and industries, but it regulates them differently. And systems have distinct characteristics that industries seldom have, such as built-in (systemic) mechanisms for discrimination, and institutionalized (yep, systemic) corruption aplenty.

When we begin by assuming that health care is a system, we assume that health care should possess those same characteristics. We assume that health care in Beverly Hills will be, by design, different than health care in Flint, Michigan. We assume that health care delivered in private settings will be different than health care accessed in public settings. We assume that some areas will have sprawling, on demand health care hubs, while others will have none. We assume that public engagement in health care is for show only, while the billionaire class and its carefully constructed echo chamber get to make all our health care decisions. We assume that health care is, and always will be, rigged. And based on these assumptions, we proceed to fix our health care “system”.

You may be tempted to dismiss these thoughts as specious demagoguery, strawmen, soapbox arguments or just plain exaggerations. After all, health care system fixing includes such socially beneficent endeavors as expanding “coverage” for the poor (Medicaid expansion), subsidizing insurance for the less poor (Obamacare exchanges), granting insurance to the sick (preexisting conditions), and a steady drumbeat of accountability, measurement and reduction in “disparities” for “vulnerable populations”. To that I would respond by pointing you to several recent utterings from public figures empowered to effect health care reforms...The Return of the BroccoliI’ve written compulsively about the apparent war on doctors in the past, and I am certain I will be writing more, but the war on people is a much more intricate subject. It’s relatively easy to separate a quarter of one percent of people from the herd, paint them as for-profit mass murderers and sic the hungry mobs on them. But then how do you subdue the mobs? For that, my friend, we have government. We have behavioral economics. We have the experts and pundits in that echo chamber. And we have the righteous souls who innocently light the fuse of every calamity.

I’m old enough to remember the debates preceding the Obamacare litigation in front of the Supreme Court, culminating with both Justice Scalia and Chief Justice Roberts pondering whether the government has it within its enumerated powers to make you buy broccoli. Before the broccoli debacle, the same libertarian lunatic fringe wondered if government can order Americans to lose weight, or if the government can mandate that we buy certain products from certain manufacturers. Of course Obamacare and its mandate to buy health insurance or be penalized by the IRS survived these outlandish challenges, and the IRS is doing its best to rake in those penalties...

My comment:

If not a "system," is it even "a market"?

"...The common wisdom
is that our health care [market] is broken and hence our government is
vigorously attempting to fix it for us through legislation, reformation
and transformation..."

Or is it a dystopian perplex of contending markets, public and private. (There's no such thing as a "free market.")

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"Who knew health care could be so complicated?"

Of ongoing interest

Cogito ergo sum

Will "artificial intelligence" (#AI) soon become simply "intelligence" capable of "reasoning" like humans?

Kind words from Dr. Jerome Carter

"Recently, I have begun reading Bobby Gladd’s KHIT.org blog. His posts (stories? vignettes?) are thoughtful and somehow put into perspective all the nonsense that happens in HIT – informative and thoroughly satisfying."

An American Sickness

On the harmful and persistent fragmentation of health care delivery

On the American way of death

An important book, IMO

The American Association for the Advancement of Science

AAAS.org

The Union of Concerned Scientists

UCSUSA.org

Health 2.0 SF Chapter

Coming soon

I've been around healthcare since 1993. Medicare QIO hospitalization outcomes analyst and network administrator, academic, next-of-kin caregiver (late daughter, late parents), and now, at 71, a Medicare bene having just finished up my own cancer treatment. This book, based in part on the long essay I wrote during my daughter's fatal illness (click Sissy's photo above), will reflect on that multifaceted journey of more than two decades.

An important read with implications for clinical cognition and workflow

Excellent physical neuroscience and neuropsychology findings on the evolution and functionality of the human brain and the adverse impact of information technology.

An impressive, comprehensive resource

NeuroTrainer brain gym

"Train from the neck up."

A very worthy San Franciso organization. I am now a volunteer.

"Lord, may I be HALF the man my dogs think I am."

Healthcare Talent

My friend of more than 20 years and former QIO colleague. Click above for LinkedIn profile page and contact info.

Northern California Cancer Support Community

Serving the Bay Area via the proven "Wellness Community" model established by the late Dr. Harold Benjamin.

An important book by public health expert Vik Khanna

I recently reviewed this book. And, while I don't agree with everything therein, I conclude it to be an important read. It's not a polemical "Repeal ObamaCare" screed at its core, by any means. Vik and I have never met (except for some emails and a Skype call), and I get no compensation for posting this. It's well worth your time.

Brave New Health

Brave New Health Foundation was created to help raise awareness about the important problems in the practice of medicine today. These fundamental problems have been hidden from the public for decades, but they affect everyone -- even you. The current healthcare system leaves patients feeling powerless, medical students overwhelmed, and doctors carrying an impossible burden. This leads to diagnostic errors, bad treatment choices, exploding healthcare costs, and preventable harm.

"Interoperability"?

Commonwell Health Alliance

"For health IT to work, it must be inherently interoperable. There are too many silos across a fragmented information system; vital data is [sic] trapped, creating inefficiency, cost and risk. It’s absolutely critical for interoperability to be built into our health IT systems, not bolted on as an afterthought. What’s more, without interoperability, future innovations in health IT are limited and work only in pockets, rather than benefiting the system as a whole."

BobbyG, ASQ member since 1989

An amazing, inspiring organization

BobbyG on Twitter

BobbyG on Pinterest

Electonic Frontier Foundation

New technologies are radically advancing our freedoms but they are also enabling unparalleled invasions of privacy.

This will never win a Grammy

Published on July 15, 2012: I was inspired to write and record this after the Supreme Court ruling narrowly upholding the PPACA, pejoratively known as "ObamaCare." Thanks to my bro' Lenny Lopez for the harmonies. Thanks to Apple for your awesome GarageBand app. The "Epistemic Hairball All Star Shoe Band" here is nothing but a multitrack sequence of Garageband library loops.

3 Still Standing

I met these folks through my long-time friend Gail Simon, the widow of my 60's bass player the late Jose Simon. Jose went on to co-found the acclaimed "San Franciso Comedy Day in the Park." This is a documentary about the scuffling lives of 3 fine stand-up comics from the era. Produced by award-winning documentary filmmakers Donna LoCicero and Robert Campos. It is very funny, poignantly so.

ThedaCare Center for Healthcare Value

CreateValue.org

Health 2.0

The conference. The media network. The innovation community.

Healthcare Information Management Systems Society

Advancing the best use of information and management systems for the betterment of health care.

International Association of Privacy Professionals

The largest and most comprehensive global information privacy community and resource.

Getting at truth?

Very interesting paper (PDF)

Down in the Weeds'

You owe it to yourself to acquire, study closely, and think hard about this book. For the record; I get nothing from this unsolicited plug. I don't know these people, all I know is what I've read.

SBM

Exploring issues and controversies in the relationship between science and medicine

Another important read (pdf)

I love this kind of stuff. It sustains and humbles me. "As politicians, advertisers, salesmen, and propagandists for various political, economic, moral, religious, psychic, environmental, dietary, and artistic doctrinaire positions know only too well, fallible human minds are easily tricked, by clever verbiage... Common language—or at least, the English language—has an almost universal tendency to disguise epistemological statements by putting them into a grammatical form which suggests to the unwary an ontological statement. A major source of error in current probability theory arises from an unthinking failure to perceive this."

Joe Flower

This book is comprehensive, articulate, learned, and the most charitable of the health policy reform books I've read.

On The Mend

The Lean imperative for health care process improvement, bringing the scientific method into workflow and management. A great read. (Note, I get nothing out of touting this or any other books I cite.)

National Nurses United

MediPedia.com

Growing repository of health-related information, all of it peer-reviewed via the Wiki model

Quotes

"An economist is a person who sees something that works in practice and tries to figure out whether it will work in theory."

- J.D. Kleinke, medical economist___

"The only person who enjoys change is a baby with a wet diaper."

"Every misspent dollar in our health care system is part of somebody's paycheck.

- Brent James, M.D., M.Stat

“We could do healthcare, at markedly higher quality, for everyone in this country, without rationing or denying anybody the care that they need, without having the government dictate how doctors practice or whether hospitals could expand, at half the cost we do it now.”

- Health Care Futurist Joe Flower

Most of the sciences, unlike parts of medical science, are not concerned with the impossible. There is not complementary and alternative physics, or chemistry, or biochemistry, or engineering. These disciplines compare their ideas against reality, and, if the ideas are found wanting, abandoned."

- Mark A. Crislip, MD

"Q: How much alcohol is too much?A: More than your doctor drinks."

- a physician I once heard speak during a CME presentation

“Just because science doesn’t know everything, doesn’t mean you get to fill in the gaps with whatever fairy tale most appeals to you.”

- Dara O’Briain

'[I]t is one small step from using the computer for "helping" doctors to monitoring them, judging them, dictating to them what to do, and withdrawing payment for computer non-compliance. The use of computer data is a multi-edged sword. It can be used for the "good," facilitating diagnosis and treatment and making it more accurate and up-to-date, and for “evil,” invading privacy, inviting security breechs, and making decisions based on the opinions of remote authorities rather than those present at the patient-doctor encounter.'

- Richard Reece, MD

“[T]here ARE statistics which are non-political. Just because The Washington Post/Fox News reports the temperature is 75 degrees doesn’t mean it’s really snowing and sunscreen is a liberal/conservative plot. Even if you earn a living being ideological.”

- Michael L. Millenson

"It is a generally a fairly convincing argument that people shouldn’t have to be subsidized to undertake a change which is in their best interest.

The reconciliation seems to be that EHR is not supposed to make a doctor’s practice more efficient and higher quality. It is supposed to make the system of care more efficient and higher quality, which is not the same thing. Those of you who took calc recall that maximizing the total of variables is not achieved by maximizing any one variable and this is a perfect example of that.

Those of you have served in combat certainly noticed that too — if everyone works as a team the unit takes fewer casualties. If you try to save your own hide, you might, but at the expense of more casualties overall."

- Al Lewis

"There are two ideas to keep in mind about Bayesian reasoning and how we tend to mess it up. The first is that base rates matter, even in the presence of evidence about the case at hand. This is often not intuitively obvious. The second is that intuitive impressions of the diagnosticity of evidence are often exaggerated."

- Daniel Kahneman, "Thinking, Fast and Slow"

"Physicians apply advanced scientific knowledge, but they must do so without the favorable conditions that experimental scientists create for themselves. Multitasking is forced on physicians, often in chaotic environments and under severe time and resource constraints."

- Lawrence and Lincoln Weed, "Medicine in Denial"

"It’s time to stop the whining about Obama care and acknowledge we already have universal health care. We just pay for it in the stupidest way possible that ensures problems are that much more disastrous and complicated when they’re finally treated."

- Mark Hoofnagle, MD, PhD

"Every act of conscious learning requires the willingness to suffer an injury to one's self-esteem. That is why young children, before they are aware of their own self-importance, learn so easily."

- Thomas Szasz, MD___

"Of course, one reason that process metrics* are so popular is that processes are much easier to define and measure than outcomes."

- The Skeptical Scalpel___

"There is an “illusion of validity” for any random data point, a seductive sense that is colored by what we hope will be true. Mountains of pharmaceutical claims are often made from mere molehills of data."

- Danielle Ofri, MD___

"Joy empowers people. It is a source of energy that enables people to hope and plan and change their lives for the better. Spend some time around someone who is relentlessly negative and how do you feel–drained, right? More and more research shows that joy is not something that just happens to you, like a bolt of lightening out of the blue. Joy is, instead, a habit to cultivate. Negative thinking and despair are the crabgrass of our souls–weeds that take root and spread, sometimes to all areas of life. Joy, in contrast, is a soul’s rose–hardy when cared for, able to put down roots over time and withstand disease and extremes. Like a rose, however, your joy can become blighted from neglect or harsh conditions. We all need to tend to our joy–to prune away the badness, and to know that, even though it may look like a prickly bare root, if you invest time in a joyous outlook, gorgeous things will bloom, even in the harshest conditions."- Dr. Jan Gurley___

"'Solutions' exist only in mathematics."

- Karen Martin___"The issue of how to regulate clinical software is, in the long run, indistinguishable from the issue of how to regulate medicine. The only difference is that medicine is practiced in the open, without secrecy, subject to peer review, and under a merit-based state license."

About Me

Cheryl D. Prince, CQA, CMQ/OE

Corporate Director of Quality, Gilbane Building Company, Concord, CA. My wife and best friend of more than four decades. Scary smart. The kindest person I ever met.

DISCLAIMER:

I write this blog wholly on my own time and my own dime. The views proffered are expressly my own as a concerned and active citizen/taxpayer (in addition to being the result of my substantive experience in the various IT fields), and in no way reflect any policy views of my former employer, notwithstanding that some of the thinking has indeed obviously been spurred by the implications of the work with which I have been doing for them.

FAIR USE POLICYI cite a ton of news and web sources spanning the breadth of relevant technical and policy domains, sometimes at substantial length. I believe I remain well within the bounds of "Fair Use," as [1] I am not doing any of this for profit, [2] I always provide attribution and links -- which, [3] far from negatively impacting any copyright holders' commercial interests, might actually increase traffic to and interest in their offerings.

Nonetheless, should I post anything of yours regarding which you have any objection, just let me know and I will remove it forthwith.